“I could not bear it”: Perceptions of chronic pain among Somali pastoralists in Ethiopia. A qualitative study

Background Pain is a major public health problem in the Global South, particularly among marginalized communities, such as Somali pastoralists. Yet, the topic of chronic pain has not yet been comprehensively studied in Sub-Saharan Africa, specifically in the Somali region of Ethiopia. Therefore, this study aims to explore the perceptions and notions of chronic pain among Somali pastoralists in this context. Methods This study used an explorative qualitative design. We performed semi-structured, face-to-face interviews with 20 purposively selected female and male Somali pastoralists with chronic pain. For data analysis, we applied the Framework Method by Gale et al. and explained patterns drawing on the Enactive Approach to Pain proposed by Stilwell and Harman. Findings Six different themes emerged: (1) “Pain as a symptom of harsh daily life”, (2) “Pain descriptions and dimensions”, (3) “Temporality of pain”, (4) “Pain-related stigma and stoicism” (5) “Mediating role of spirituality”, and (6) “Impact of pain on daily life activities”. Conclusions Somali pastoralists described their chronic pain as a multicausal and relational experience. Pastoralists (especially women) commonly refrained from communicating their pain and represented aspects of social stigma and stoicism. The mediating role of spirituality aided pastoralists to make sense of their pain and to ease its impact on their harsh daily life. The findings of this study can contribute to raise awareness of chronic pain issues among pastoralists. They highlight the need for policymakers to prioritize the improvement of pastoralist-specific pain management. Necessary resources and skills should be available within health care facilities. Pain management should be accessible, affordable and culturally acceptable for this population.


Comments from Reviewer 1
Although, this study aims to explore the perceptions and notions of chronic pain among Somali pastoralists but I think this illustration cannot add more to the scientific research and the authors better use a control group from other country or another population to strenghthen the study.
Thank you for this comment.We argue that qualitative research has a great deal to offer when trying to gain indepth insights into persons' illness experiences.From our point of view, the findings are completely novel in this field of research.To our knowledge no other study has examined chronic pain experience in this unique context and in this marginalized population.Indeed, these initial findings can provide valuable insights and orientation for future studies (as described in the "strengths and limitations").In addition, by drawing on studies investigating Somalis and/or pastoralists in other countries, we can make relevant comparisons -Methods section, p. 7, lines 181-186 -Strengths and limitations, p. 23, lines 570-575/590-593 (e.g., lines 483-493).Furthermore, we made sure to now point out that the various settings of this study also allowed for interesting comparisons (home as well as biomedical).Comments from Reviewer 2 I reviewed a manuscript titled "Perceptions of Chronic Pain Among Somali Pastoralists in Ethiopia."This is a small descriptive study that looked at a diverse group of adult pastoralists and agro-pastoralists dealing with chronic pain in Ethiopia.The study used ethnographic research techniques.Pastoralists are a group often marginalized socially and geographically, known for enduring many hardships in their daily lives.When it comes to chronic pain, they mainly rely on traditional and spiritual health practices, with Western biomedical approaches being quite rare.The authors referenced a study by Kawza et al., which found that only 10% of pastoralists in Southern Ethiopia used biomedical healthcare facilities when they were sick.
Main strength of this study is how it enhances our understanding of the sociocultural aspects of pain perception within this isolated population.
However, a major weakness lies in the small sample size and the potential bias towards patients who use biomedical healthcare facilities.
Thank you for your considerations and for highlighting these important points.We added further information on the utilization of health services specifically for Somali pastoralists.As elaborated briefly above, we are convinced that qualitative studies with small sample sizes can provide valuable insights into a population, for which we have very limited information on pain perception.The small sample size was mentioned in the "strengths and limitations" section of the paper.We have now added more information on the sample size of the preceding focus group discussions.Indeed, most interviews took place in biomedical healthcare facilities.However, we also interviewed n=5 pastoralists affected by chronic pain in their home.We elaborate on this in the section "Setting and recruitment".In addition, we highlight the pastoralists' care itineraries in the results, thereby describing steps taken before they came to the health facility.In the "Conclusion", we added the recommendation to investigate how pastoralists are burdened by chronic pain and how they cope with chronic pain within their communities.